7/18/19

1

TB Infection Control and Case Management

James Sunstrum, M.D.TB Consultant

Michigan Dept. of Health and Human Services

Nnenna Wachuku, RN, MSNCommunicable Disease/ TB Program Supervisor

Wayne County Health Department

Objectives

• When to place a patient INTO isolation

• When to remove a patient FROM isolation

• How to best PROTECT you and your staff from TB infection

• How to REDUCE the duration of isolation

• When can a TB patient go home?

• What is the role of Public Health Department?

1

2

7/18/19

2

TB Transmission (4)

Dots in air represent droplet nuclei containingM. tuberculosis

Hierarchy of Infection Control

Respiratory Protection

Administrative Controls

Environmental Controls

3

4

7/18/19

3

Administrative controls are the first and most important level of the hierarchy.

Administrative Controls

Environmental

Suspect TB if…

• Cough > 2‐3 weeks

• Gross hemoptysis

• Exposure to TB?

• +PPD or IGRA?

• From endemic country?

• Substance abuse or HIV?

5

6

7/18/19

4

Case ExampleMy hospital ER August 2018

• “Blood in vomit, x 1 day, pt reports 30 weeks pregnant, some abdominal cramping, denies vaginal bleeding. pt states blood tinged sputum with cough also; pt does report dx pneumonia 1 month ago and hospitalization at st joe's”

• ER physician notes gross hemoptysis 2 tablespoons.

• Notes patient from Guinea in 2016

• Airborne Infection Isolation ordered before

X‐rays done

7

8

7/18/19

5

Cavitary tuberculosis

What was the most important component for Infection Control?

• Administrative component

• Cognitive awareness on the part of ER physician

• Isolate 10 patients to discover 1 case of

active TB!

9

10

7/18/19

6

7 factors that affect the infectiousness of a TB patient.

• Presence of a cough

• Chest x‐ray showing cavity in lung

• Positive acid‐fast bacilli sputum smear result

• TB of lungs, airway, or larynx

• Patient not covering mouth or nose when coughing

• Not receiving adequate treatment

• Undergoing cough‐inducing procedures

Airborne Infection Isolation (AII)

• Private room

• Negative pressure with 6‐12 air exchanges per hour

• Signage

• N95 respirators

11

12

7/18/19

7

Ventilation Technologies (6)Mechanical Ventilation

• AII rooms are designed to prevent spread of droplet nuclei expelled by patient

– Negative pressure– Clean air flows from corridors into AII room

• Air cannot escape AII room 

– Exhausted outdoors or passed through filter

Image credit: Francis J. Curry National TB Center

13

14

7/18/19

8

Respirator for Health‐Care Workers

• Health‐care worker wearing a respirator

• Respirators– Designed to filter out droplet 

nuclei from being inhaled by the health‐care worker and other individuals

– Should properly fit different face sizes and features

– Should NOT be worn by the patient

Surgical Mask for Persons with Infectious TB Disease

• Infectious TB patient wearing a surgical mask

• Surgical masks

– Designed to stop droplet nuclei from being spread (exhaled) by the patient

– Should NOT be worn by the health‐care worker

15

16

7/18/19

9

What is a placebo mask?

• Only 1 strap, instead of 2

• Held to face with a hand

• Facial hair interferes

with seal

The pregnant TB patient is moved from ER to an IsolationRoom on the Medical Floor…..

• When can the ER room be used again?

• 46 minutes to remove 99% of airborne contaminants

• 60 minutes is considered adequate.

• MMWR Dec. 30, 2005

17

18

7/18/19

10

>90% of Isolation patients don’t have TB. How do we get them released quickly?

• Sputum quality critical

• Induce with nebulizer if needed

• AFB smear

• Plus NAAT (PCR) regardless whether AFB smear is positive or negative.

http://www.tbcontrollers.org/resources/airborne-infection-isolation

19

20

7/18/19

11

21

22

7/18/19

12

Remove from Isolation?

• Airborne precautions can be discontinued when infectious TB disease is considered unlikely and either – Another diagnosis is made that explains the clinical syndrome, 

– The patient has three negative AFB sputum smear results, or 

– The patient has a sputum specimen that has a negative NAA test result and two additional sputum specimens that are AFB‐smear negative.*

or

– GeneXpert ® neg x 1 (or 2) ‐ Good Sputum samples!**

From John Bernardo, MD

Remain in isolation

• TB is confirmed, or very strongly suspected.

• Start effective TB medications

• Intubation is not a substitute for Isolation status

23

24

7/18/19

13

Duration of Isolation once TB treatment started

• Patients rapidly become noninfectious after effective multiple‐drug chemotherapy instituted.

• Rapid elimination of viable MTB from sputum, and reduction in cough frequency.

• But no ideal test exists to assess the infective potential of a TB patient.

Start INH, RIF, PZA, EMB

• 90% reduction in viable MTB in 48 hours

• 99% reduction by 14‐21 days of treatment.

• Is patient going home, or remaining in hospital?

25

26

7/18/19

14

Criteria for determining when during therapy a patient with pulmonary TB has become noninfectious (MMWR Nov. 4, 2005)

• Negligible risk of MDR TB

• Received standard TB treatment 14‐21 days

• Complete adherence by DOT

• Clinical improvement

• Close contacts identified and evaluated.

• AFB smears show reduced or negative organisms

What Happens When a TB Case is Reported –Local Health Department Responsibilities

• Nurse Case Manager/DOT Nurse receives the report or

phone call from ICP/MD

– Responsible for the outcome of TB suspects/cases/contacts

from initiation of treatment until discharge

– Obtain patient’s complete hospital record e.g. radiographic

images, lab reports, etc.

27

28

7/18/19

15

What Happens When a TB Case is Reported-2

– Review report for medical information and accuracy

• How infectious or potentially infectious is the patient

• Are they medically stable

• Correct regimen

• Barriers to discharge

– Homeless

– Vulnerable population in the home

What Happens When a TB Case is Reported-3

•Outreach worker or DOT nurse interviews the patient in the hospital within 3 days after receiving the report

– Reviews hospital records

– Hospital visit

– Evaluate patient’s knowledge and beliefs about TB

– Provide education based on patient’s current knowledge and

ability to comprehend written, verbal and visual information

– Contact investigation is initiated

29

30

7/18/19

16

What Happens When a TB Case is Reported-4

– Home visit is made to verify address, living arrangements and

contacts

– Establishes plan for DOT upon discharge and medical

supervision – clinic vs. private MD

– Ensures patient has follow-up appointment and no interruption

in treatment

– Participates in discharge planning

– Builds rapport

Communication with Case Management and Public Health

• Infection prevention, case management and public health must work together in discharge planning

• Specific needs of the patient must be identified early on

• No two cases are the same

• Team must decide best plan of care after discharge for the patient

31

32

7/18/19

17

Discharge Planning-2

Discharge Planning -2

• Request 48 hours notice prior to discharge

• Request not to have patient discharged on a Friday

• Ensure the criteria for discharge is met utilizing the Discharge Planning Checklist

33

34

7/18/19

18

Going Home

• No minimum number of days of anti‐TB treatment before going home if:

– On treatment, likely to be susceptible

– Showing clinical improvement

– DOT arranged

– Home Isolation agreement

– Does not need negative AFB smears

Recommended Criteria for Hospital Dischargeof the Infectious Patient

• The patient has a stable residence that is validated by the TB nurse case manager

AND • The residence is not shared by any person(s) who is a

member of a vulnerable population unless the person(s) has been diagnosed with LTBI– Vulnerable population are those individuals who are immuno-

compromised for any reason or <5 years of age OR

• TB has been ruled out as the cause of the patient’s illness??

35

36

7/18/19

19

Recommended Criteria for Hospital Discharge-2

• If the patient:– Is a resident of a congregate living facility

– Is homeless

– Reports a private residence that the TB nurse case manager has not verified as being valid or stable OR

– Has a private residence where uninfected members of a vulnerable population reside

If any of the above conditions exist, the patient MUST meet one of the following criteria before discharge: →

• Have 3 consecutive sputum smears negative for AFB collected at least 8-24 hours apart (with one early morning sputum)

• Have at least one sputum culture negative M.tbafter TB treatment has been initiated

• Negative NAAT

• Is granted an exemption by the Health Dept. based on clinical evidence and patient interview, if none of the above conditions have been met

• Had no sputum smears + for AFB, been on TB treatment for at least 2 weeks and no current respiratory symptoms

Recommended Criteria for Hospital Discharge-3

37

38

7/18/19

20

• If the infectious or potentially infectious patient does not meet the criteria for discharge or patient non-adherence/risk of flight has been documented during the hospitalization, discharge should be delayed

Recommended Criteria for Hospital Discharge-4

Appropriate DischargeProtects the community against transmission• Patients can only be discharged while infectious

with:– Stable residence – No vulnerable residents in household– Agreement to self isolate until non-infectious

• Otherwise, must be kept in an Airborne Infection Isolation (AII) room until documented non-infectious

• Must coordinate discharge with TB nurse case manager

39

40

7/18/19

21

Outpatient diagnosed with TB

• Prompt response by the Nurse Case Manager/DOT Nurse is needed to have the patient started on treatment and evaluate the household contacts

• A home or clinic visit should be initiated quickly to assess the patient

• An on-going assessment should occur every DOT/monthly clinic visit

Infectious Patient Diagnosed Outpatient

• Collect a sputum

• Clinic appointment as soon as possible

• Discuss DOT

• Utilize patient–centered approach

• Work collaboratively with patient, the physician and the family to identify treatment barriers and develop strategies to meet the patient needs

• Evaluation of household, workplace and other contacts

41

42

7/18/19

22

1st Clinic Visit

• Provide a surgical mask and instruct patient on proper use, for clinic appointment

• Isolate patient in a separate exam room

• If a patient is very infectious, try to schedule as the last appointment to have less patients in the clinic or first appointment before the other patients come in.

• A note is placed on the chart to alert the clinic staff especially the check-in staff that patient is potentially contagious

• Do not make the appointment during appointments of vulnerable populations (e.g. children, HIV)

Monitor Patient

• Collect sputum monthly until negative cultures/smears for 2 consecutive months

• Monitor patient for symptom improvement

• Monthly visit to TB clinic

• Keep infection control measures in place until patient is no longer infectious

43

44

7/18/19

23

Returning to work or school

• 14 days treatment minimum

• Clinical improvement

• Number of AFB decreasing

• Appropriate worksite

• Outdoor work or solitary work may return earlier

• Decision must involve Health Department.

Immediate/Imminent Public Health Risk

• Definition: A patient with suspected or confirmed infectious or potentially infectious TB disease who does any of the following:– Threatens to leave

hospital against medical advice (AMA)

– Leaves hospital AMA

– Verbalizes or demonstrates non-adherence with infection control measures

– Refuses to take medications as prescribed

– Threatens to travel on public conveyance

45

46

7/18/19

24

THINK TB

THANK YOU!

QUESTIONS? 

47

48

7/18/19

25

Think TB

• Health care workers must be trained to ask questions that will facilitate detection of persons who have suspected or confirmed TB infection

• The medical evaluation must be conducted in the patient’s primary language using an interpreter if needed

• There should be ‘red flags’ or key words that raise the suspicion for TB

TB Triage Reviews with ER, Pulmonary and Infectious Disease staff

• Review last year’s active TB cases

• Review variable radiological presentations of TB

• Review the time from presentation to placement in Airborne Infection Isolation

49

50

7/18/19

26

What Happens When a TB Case is Reported –Local HD Responsibilities

• Nurse Case Manager/DOT Nurse receives the report or

phone call from ICP/MD

– Responsible for the outcome of TB suspects/cases/contacts

from initiation of treatment until discharge

– Obtain patient’s complete hospital record e.g. radiographic

images, lab reports, etc.

What Happens When a TB Case is Reported-2

– Review report for medical information and accuracy

• How infectious or potentially infectious is the patient

• Are they medically stable

• Correct regimen

• Barriers to discharge

– Homeless

– Vulnerable population in the home

51

52

7/18/19

27

What Happens When a TB Case is Reported-5

It is crucial that the eight elements of case management are utilized:

1. Case Finding

2. Assessment

3. Problem identification

4. Development of plan of care

5. Implementation

6. Outcome identification

7. Evaluation

8. Documentation

Notification of Precautions to Protect Public Health

• A document that explains the appropriate precautions the patient needs to take while infectious is reviewed with the patient at the hospital or home

• It outlines the infection control measures with which the patient must adhere to in order to protect the public until rendered non-infectious

53

54

7/18/19

28

TB CASE MANAGEMENT:INPATIENT AND OUTPATIENT SETTINGS

Wayne County Department of

Health, Veterans & Community Wellness

Nnenna Wachuku, RN, MSNCommunicable Disease/ TB Program Supervisor

55

56

7/18/19

29

Communication with Case Management and Public Health

• Infection prevention, case management and public health must work together in discharge planning

• Specific needs of the patient must be identified early on

• No two cases are the same

• Team must decide best plan of care after discharge for the patient

Discharge Planning

• Request 48 hours notice prior to discharge

• Request not to have patient discharged on a Friday

• Ensure the criteria for discharge is met utilizing the Discharge Planning Checklist

57

58

7/18/19

30

Assessment should include:

• Weight

• Vitals

• Assessment of symptoms

• Medical history

• Interview to establish infectious period

• Assessment of living space and household contacts

• Is there space to home isolate

• Providing the patient with a surgical mask

• Educate patient and family on TB and home infection control measures

Initial Visit with the Nurse

Think TB• Assess all TB infection for TB disease

• “THINK TB!” - there should be a triage plan and if possible a separate room to place the patient

• Patient must be offered a surgical mask

• Precautions should be initiated for signs or symptoms of TB disease or if patient has known TB disease and has not completed anti-TB treatment

• Use signage in the waiting area of TB symptoms and cover your cough

• Train staff

59

60

7/18/19

31

‘Cover Your Cough!’

• Consider TB for any patient with symptoms of infection in the lung or airways

• Cough for > 3 weeks• Bloody sputum of

hemoptysis• Hoarseness• Other signs, symptoms

and factors• Loss of appetite

• Unexplained weight loss• Fever• Fatigue• Chest pain• Travel history • Homeless population• Recent incarceration or

residence in a group setting

Think TBSymptoms related to cough/respiratory tract

61

62

7/18/19

32

TB RESOURCES

Centers for Disease Control and Prevention (CDC)https://www.cdc.gov/tb/

Michigan Dept. of Health &  Human Services (MDHHS)www.michigan.gov/tbinfo

Rutgers Global Tuberculosis Institute New Jerseyhttp://globaltb.njms.rutgers.edu/

63

64

7/18/19

33

ACKNOWLEDGMENT

• Rutgers Global Tuberculosis Institute New Jersey

• Patty Woods RN, MSN

• MI Bureau of Epidemiology and Population Health

• Helen Mcguirk, MPH

Thank You !

Questions?

65

66